national action plan for containment of antimicrobial ... · antimicrobial resistance (amr) has...

1

National Action Plan for

Containment of

Antimicrobial Resistance:

Myanmar

2017-2022

(Draft)

July, 2017(Version 01)

2

Table of Contents

Abbreviations and Acronyms ...................................................................................... 5

Executive Summary ................................................................................................... 8

Background .............................................................................................................. 11

Setting the Context: From Global to National Action Plans ................................... 11

Situation Analysis and Assessment ...................................................................... 12

Figure 1: Status of implementation of AMR containment programme/ initiatives in

Myanmar, by phase of implementation………………………………………………. 20

National Action Plan on AMR (2017 – 2022) ............................................................ 21

Goal, Objectives and Guiding Principles ............................................................... 21

NAP Development Process .................................................................................. 21

Country Response.................................................................................................... 24

Governance .......................................................................................................... 24

National Multisectoral Steering Committee (NMSC) for Antimicrobial Resistance ... 24

National AMR Coordinating Centre (NACC) ............................................................. 24

Logistics of the NACC .............................................................................................. 25

Roles and responsibilities of NACC.......................................................................... 25

Appointing a National Focal Point ............................................................................ 26

Forming Technical Working Groups ......................................................................... 26

Constituting Specialised Task forces........................................................................ 27

Figure 2: NAP Governance structure in Myanmar, 2017 to 2022 ………………… 28

Strategic Plan ........................................................................................................... 29

Strategic Objective 1: AWARENESS .................................................................... 29

3

Objective 1.1: To improve awareness of AMR amongst the general public and

professionals ............................................................................................................ 29

Objective 1.2: Improve knowledge of AMR and related topics in professionals

through professional education and training deployed at the national scale ............ 31

Strategic Objective 2: SURVEILLANCE OF AMR ................................................ 33

Objective 2.1: Set up a national surveillance system for antimicrobial resistance

under the leadership of a National Coordinating Centre. .......................................... 34

Objective 2.2: Build laboratory capacity under the leadership of a National Referral

Laboratory (NRL) to produce high-quality microbiological data for patient and food-

safety management and support surveillance activities. .......................................... 36

Objective 2.3: Develop a multi-centric surveillance system on the national scale to

provide early warning of emerging resistance and monitoring of secular trends at

national and sub-national levels. .............................................................................. 38

Strategic objective 3: HYGIENE, INFECTION PREVENTION AND CONTROL

(IPC) ......................................................................................................................... 40

Objective 3.1: To establish a national infection prevention and control programme

through full implementation and compliance with the IPC guidelines within healthcare

settings, animal husbandry systems, fisheries and the food chain ........................... 41

Objective 3.2: Decrease Hospital Acquired Infection (HAI) and associated AMR

through facility based HAI surveillance programme (Human Health) ....................... 43

Objective 3.3: To limit the development and spread of AMR outside health settings44

Strategic Objective 4: OPTIMISE USE OF ANTIMICROBIAL MEDICINES .......... 46

Objective 4.1: Establish a national AMR containment policy, Antimicrobial

Stewardship Programmes (AMSP) and Standard Treatment Guidelines (STG) at the

national scale for prudent use of antimicrobials ....................................................... 46

4

Objective 4.2: Regulation of post-marketing quality of drugs under the leadership of

an NRA/DRA to ensure access to quality antibiotics ................................................ 48

Objective 4.3: Establish mechanisms to monitor antimicrobial usage on a national

scale to inform interventions to reduce overuse and promote prudent use of

antimicrobial substances .......................................................................................... 51

Strategic Objective 5: (ECONOMIC) CASE FOR SUSTAINABLE INVESTMENTS

AND INCREASE INVESTMENTS IN NEW MEDICINES, DIAGNOSTIC TOOLS,

VACCINES AND OTHER INTERVENTIONS TO REDUCE ANTIMICROBIAL USE

............................................................................................................................... ..53

Objective 5.1: To promote sustainable investment in new medicines, diagnostic

tools, vaccines and other interventions by developing a strategic research agenda

and national research policy ..................................................................................... 53

Way forward ……………………………………………………………………………. 56

References ……………………………………………………………………………… 57

Annexure 1: Interpretation of phase of AMR prevention and control program

implementation 60

Annexure 2: Terms of reference of individual Technical Working Groups and their

structure ................................................................................................................... 62

5

Abbreviations and Acronyms

AGISAR : Advisory Group on Integrated Surveillance of Antimicrobial

Resistance

AGPs : Antimicrobial Growth Promoters

AMA : Antimicrobial Agent

AMP : Antimicrobial Management Programme

AMR : Antimicrobial Resistance

AMSP : Antimicrobial Stewardship Programme

AMU : Antimicrobial Use

APAC : Asia-Pacific Countries

APIs : Active Pharmaceutical Ingredients

ASCU : AMR Surveillance Coordination Unit

AUSC : AMU Surveillance Coordination Committee

CEU : Central Epidemiology Unit

CME : Continuing Medical Education

CODEX : Codex Alimentarius Collection Of Food Standards

DG : Director General

DMR : Department of Medical Research

DoHRH : Department of Human Resource for Health

DRA : Drug Regulatory Authority

EMLs : Essential Medicine Lists

EQAS : External Quality Assessment Scheme

FAO : Food and Agriculture Organization

GAP : Global Action Plan

GASP : Gonococcal Antimicrobial Surveillance Programme

GDP : Gross Domestic Product

GFATM : Global Fund for AIDS, TB and Malaria

GFN : Global Foodborne Infections Network

GP : General Practitioner

HAI : Hospital Acquired Infection

HCF : Health Care Facilities

6

HICC : Hospital Infection Control Committee

HPAI : Highly Pathogenic Avian Influenza

ICC : Infection Control Comittee

IHR : International Health Regulation

IPC : Infection Prevention and Control

KAP : Knowledge Attitude and Practice

LVBD : Livestock, Breeding and Veterinary Department

M&E : Monitoring and Evaluation

MDR : Multidrug Resistant

MMA : Myanmar Medical Association

MMC : Myanmar Medical Council

MNA : Myanmar Nursing Association

MoALI

MoE

: Ministry of Agriculture, Livestock & Irrigation

Ministry of Education

MoHS : Ministry of Health & Sports

MS : Member States

NACC : National AMR Coordinating Centre

NAP : National Action Plan

NDRA : National Drug Regulatory Authority

NFP : National Focal Point

NHL : National Health Laboratory

NMSC : National Multi-Sectoral Steering Committee

NRA : National Regulatory Authority

NRL : National Referral Laboratory

OIE : World Organisation for Animal Health, Organisation mondiale

de la santé animale

OTC : Over the Counter

PCU : Population Correction Unit

PHL : Public Health Laboratory

R & D : Research & Development

STG : Standard Treatment Guideline

TWG : Technical Working Group

7

UNAIDS : The Joint United Nations Programme on HIV/AIDS

UNCEF : United Nations Children’s Emergency Fund

UNFPA : United Nations Population Fund

UNGA

VDL

: United Nations General Assembly

Veterinary Diagnostic Laboratory

VDRL : Venereal Disease Research Laboratory

WaSH : Water, Saniation and Hygiene

WHA : World Health Assembly

WHO CC : WHO Collaborating Centre

WHO SEARO : World Health Organization Southeast Asia Regional Office

ZELS : Zoonoses and Emerging Livestock systems

8

Executive Summary

Myanmar, as a country going through rapid socio-political transition and institutional

development also suffers with a high burden of infectious disease. An ongoing

challenge has been to effectively reach its 51 million population, most of whom battle

tuberculosis, acute respiratory infections, diarrhoea and malaria including amongst

under-five children.

Limited research data on the occurrence of resistant organisms in the nation have,

makes it hard to estimate the exact antimicrobial resistance (AMR) scenario. Limited

peer reviewed evidence indicates significant divergence from the average resistance

trends in APAC region. Nevertheless, several key steps by Government of Myanmar

have been instrumental in paving the way for the country to join other nations in the

South East Asia Region to speed up its plan on addressing the AMR crisis.

Combating antimicrobial resistance would, however, require highest political

commitment, multi-sectoral coordination, sustained investment and technical

assistance.

A situation analysis was undertaken in September 2016 using a tool developed by

WHO SEARO based on discussions between national multisectoral steering

committee members, senior technical leaders of the national health authorities and

veterinary sector and WHO team. It identified opportunities, challenges and

implementation gaps to improve implementation of NAP AMR in ways that could

meet the 68th World Health Assembly (WHA) resolution on AMR.

The indicators in the situation analysis protocol were grouped under the heads of

National AMR Action Plan in line with GAP-AMR; National AMR surveillance system;

Antimicrobial Stewardship and Surveillance of antimicrobial use; Infection Prevention

Control in healthcare settings; Awareness raising; Research & innovation and One-

Health engagement. Each of these focus areas were consistent with the five

strategic objectives of the WHO GAP-AMR, namely the phases of exploration and

adoption; programme installation; initial implementation; full operation and

sustainable operation.

The situation analysis revealed commitment among political and technical

leadership, supporting AMR containment efforts as is reflected in the formation of a

National Multi-Sectoral Steering Committee (NMSC). Several existing strengths and

initiatives have been mapped as building blocks of an effective NAP AMR. These

include a strong laboratory network, existing Infection control and biosecurity

programs in human and animal health sectors and a National One Health Strategy

which identifies AMR as a priority. A fully functional national drug regulatory authority

to oversee regulation and licensing, pharmacovigilance and market authorisation is

9

another strong element to leverage. Next, initiatives are being taken to develop

national standards and guidelines such as the national drug policies were updated

essential medicines lists and standard treatment guidelines including for antibiotic

prescription are being drafted. Public health system strengthening is an ongoing

process while formal campaigns are consolidated or launched focusing on

vaccination, sanitation and hygiene at community level.

The National Action Plan on AMR for the period 2017 – 2022 takes these efforts

further, reinforcing the government’s commitment to make universal healthcare and

animal welfare, food security a reality. Based on implementation of the five strategic

objectives, each of which has its specific objectives, strategic interventions and key

activities, the NAP AMR charts a new phase in Myanmar’s journey towards

achieving goals related to AMR compliance.

To implement strategic objective 1 related to bridging knowledge and awareness

gaps, NAP AMR will establish an evidence-based public communications

programme on a national scale to improve awareness of AMR amongst general

public and professionals. By 2022, the country would have carried out nationwide

evidence based awareness campaigns with regular Monitoring and Evaluation

(M&E).Necessary revision and pilot scale implementation of curricular revisions

would also have been undertaken by 2022.

To implement strategic objective 2 related to surveillance of AMR, steps would be

taken to understand how resistance develops and spreads. This will be done by

building on existing strengths of functional national hospital and public health

laboratory network in human and animal health sectors, having a nationwide AMR

surveillance system in place along with a national early warning system to identify

early the emergence of resistance in priority pathogens and to critical antimicrobials

by 2022.

To implement strategic objective 3 related to strengthening of hygiene, infection

prevention and control, a national infection prevention and control programme would

be implemented in compliance with IPC guidelines within healthcare settings, animal

husbandry systems and food production systems. Also, actions to decrease Hospital

Acquired Infection (HAI) and associated AMR through facility based HAI surveillance

programme (Human Health) would be conducted. Hygiene and sanitation related

campaigns in community settings will be conducted through systematic health

promotion activities.

To implement strategic objective 4 related to optimising use of antimicrobial

medicines, a national AMR containment policy would be announced along with a

series of measures on Antimicrobial Stewardship Programmes (AMSP) and

Standard Treatment Guidelines (STG) at the national scale for prudent use of

antimicrobials. Moreover, mechanisms would be established to monitor antimicrobial

10

usage on a national scale to inform interventions to reduce overuse and promote

prudent use of antimicrobial substances. Regulatory structures will be strengthened

and newer structures established, especially in veterinary sector.

To implement strategic objective 5 related to building a case for sustainable

investments for new medicines, diagnostic tools/vaccines/aids that help bring down

use of AMR, it is being mooted to build institutional capacity in the context of

research on AMR. A strategic research agenda that is relevant to the Myanmar

context will be developed and implemented. This will be done in large part, through

leveraging existing capacity, build additional capacity as well as through international

collaborations.

Most of these activities will be implemented by the key actors as outlined in the

proposed strategic plan that covers the period 2017-22. Following submission of the

final report to the World Health Assembly, the Government of Myanmar will continue

with its deliberations and planning process under the leadership of National Multi-

Sectoral Steering Committee (NMSC).

11

Background

Setting the Context: From Global to National Action Plans

Antimicrobial resistance (AMR) has emerged as one of the biggest public health

threats of the modern epoch. At the 68th World Health Assembly (WHA) in May 2015,

a global action plan on AMR (GAP AMR) was adopted in response to the

acknowledgement of this emerging crisis (1). The GAP AMR has been developed at

the request of the Health Assembly in keeping with resolution WHA67.25 of May

2014, which was reflective of the global consensus that AMR was a major threat to

human health.

The GAP AMR has advocated for the One Health approach to form the basis for the

global response to AMR, especially in case of developing countries, which are

expected to contribute to the increasing trends of antimicrobial agent (AMA)

consumption and therefore, likely to be at a higher risk of emerging resistant

microbes (2–4). The need for this was further stressed at the 2015 WHA through

resolution WHA68.7.1

Consolidating the position of the GAP AMR, the global political will come together to

further commit to the cause of containment of AMR at the United Nations General

Assembly (UNGA) at the high level meeting on AMR on 21 September, 2016, in New

York (5). At this meeting, global leaders committed to “taking a broad, coordinated

approach to address the root causes of AMR across multiple sectors, especially in

human health, animal health and agriculture” (5).

One of the overarching requirements outlined by the GAP AMR was that all Member

States (MS) should develop their own, tailor made National Action Plans on AMR

(NAP AMR), duly aligned with the principles and approaches espoused by the GAP

AMR by May 2017.2

The process of framing a contextually-driven NAP AMR will provide a baseline

understanding of the local AMR situation, along with highlighting gaps and available

capacities. This will serve as valuable information, allowing different countries to

customise their NAP AMR as per their local realities.

1Recognising that the main impact of antimicrobial resistance is on human health, but that both the contributing

factors and the consequences, including economic and others, go beyond health, and that there is a need for a

coherent, comprehensive and integrated approach at global, regional and national levels, in a “One Health”

approach and beyond, involving different actors and sectors such as human and veterinary medicine, agriculture,

finance, environment and consumers. 2 (3)to have in place, by the Seventieth World Health Assembly, national action plans on antimicrobial

resistance that are aligned with the global action plan on antimicrobial resistance and with standards and

guidelines established by relevant intergovernmental bodies;

12

The process of framing a NAP AMR for Myanmar was initiated through a situation

analysis, which provided details of the existing AMR situation, gaps and capacity in

the local context.

Situation Analysis and Assessment

Located in Southeast Asia, with total area of 676,600 square km and population of

51 million, Myanmar is surrounded by India and Bangladesh on the west and China,

Laos and Thailand on the South East(6). In 2011, the country installed its first civilian

government. Ever since, the country has been going through rapid and significant

socio-political changes and institution building.

Myanmar is known to be surrounded by porous borders with neighbouring countries.

This has not only socio-political implications but implications for movement of

diseases and pathogens alongside humans and animals including drug resistance

pathogens. Porous borders have also been implicated in illegal movement of drugs

and pharmaceuticals for both humans and animals that may or may not be of

optimum quality (7).

Compared to other countries in Southeast Asia, Myanmar lags behind on key health

indicators(8). The country suffers from a high Infectious diseases burden which

contribute to result in greatest proportion of the number of years of life lost, HIV

prevalence and malaria incidence nearly double the respective regional averages

(8). High infectious disease burden and its complexity is also represented by high TB

incidence and MDR TB, the latter being among highest in the region at double the

regional average(9).

High MDR TB rate could also be considered an indicator of the problem of

antimicrobial resistance(AMR) in general, among common pathogens in both

hospital and ambulatory settings. Given multifactorial origin of AMR as a result of

antimicrobial use (AMU) in human, animal and food production sectors, it is

important to understand the nature and extent of problem and its drivers including

socio-cultural, system and policy drivers. This understanding is necessary to inform

interventions for effective containment of AMR. However, with the exception of

malaria, there is extremely limited peer reviewed evidence or grey literature on

existing situation of AMR in common bacteria in Myanmar in hospital as well as

community settings in both human and animal sectors.

Antimicrobial resistance and use in human health sector

In the scenario of limited local production, antimicrobials such as β-lactams,

tetracycline, fluoroquinolones, aminoglycosides, macrolides and sulphonamides and

most are imported from Asian and European countries (personal communication

13

from Director General(DG) (Department of Food & Drug Administration). However,

limited evidence exists on AMR burden, AMU and their trends in Myanmar.

Documented evidence doesn’t allow comparison with regional averages. For

example, in a study on hospitalised patients during 2009 to 2013 in Myanmar,

resistance to Enterococcus spp, to ampicillin was reported as 30.8% and 68.8% to

erythromycin (10). This is much lower than the APAC regional average of 68.5%

resistant to ampicillin in Enterococcus reported in 2011 (11). Some evidence on

AMR in Myanmar has been reported from studies conducted in border areas,as

these areas have been more accessible to patients and samples in the past. In a

study on non-pregnant adults on the Thailand–Myanmar border in 2013-2014,

resistance percentage in E.coli was reported as: ampicillin 70.1%, ceftriaxone

20.9%, co-amoxiclav 7.5%, cotrimoxazole 62.7%, Ciprofloxacin 20.9%, gentamicin

20.9%, nitrofurantoin & meropenem 0%. These rates are again significantly different

from APAC averages: 44.6% to co-amoxiclav, cotrimoxazole 64.4%, ceftriaxone

59.4%, gentamicin 42.6%, meropenem 3.3% (12). Similar unexpectedly low

resistance was reported to common bacterial isolates in blood cultures from

paediatric patients in Yangon Children Hospital (13).

The rising problem of AMR in Myanmar has however, been demonstrated by Lestari

et al. in their review of literature of peer reviewed publication between January 1,

1995 and January 1, 2007(14). In 1984 and 1985, no resistance to trimethoprim-

sulfamethoxazole was observed among Shigella spp in Myanmar, in 1989 it was

48% and in 1993, 63% of isolates were resistant. In Myanmar, tetracycline

resistance among Shigella spp increased over the years from 0% in 1980, 41% in

1984, 63% in 1985, 90% in 1991 to 91% in 1993. For chloramphenicol, there has

been a steady increase in resistance rates over the years in Myanmar: from 0% in

1980, 41% in 1984, 63% in 1985, 75% in 1989, 90% in 1990 to 91% in 1993(14).

Antimicrobial resistance and use in animal health, aquaculture and food

production sectors

Agriculture is the backbone of the Myanmar economy: the sector contributes to

37.8% of Gross Domestic Product (GDP), accounts for 25 to 30 % of total export

earnings and employs 70 % of the labour force (15). Livestock and fisheries account

for 20% of agricultural GDP of Myanmar (16). Livestock and fisheries sector is

proposed to expand to achieve food security and self-sufficiency. National livestock

policy has laid large emphasis on poultry production as well as dairy cattle while

retaining a rural focus and strengthening small holder animal farms (15).

While both marine and inland fisheries are responsible for majority of production,

increased emphasis to harness the potential of aquaculture is reflected in special

plans of Government of Myanmar. Special livestock and fisheries development

committees and task forces have been set up in the past to work on a multi-year

14

plans for extended breeding and production of fish and shrimp including technical

support from global knowledge institutes (17,18).

Alongside the growth of incomes and population, the demand for livestock products

is expected rise sharply: for poultry meat the market is expected to grow annually

with 15%. The market growth for dairy products is expected to be even higher: 30 –

100% in the upcoming 10 years (17). Rapid increase in production of livestock and

aquaculture are known to involve intensive approaches that make animals prone to

infections and therefore lead to greater need for AMAs which is reflected in the

recent projections. Based on livestock intensification patterns, China, Brazil and

India are current hotspots, and future hotspots are Myanmar, Indonesia, Nigeria,

Peru and Vietnam (19). Currently in SEA, Indonesia, Vietnam, and Myanmar are the

three leading consumers of antimicrobials for farm use on a total per-country basis.

Among the 50 countries with the largest amounts of antimicrobials used in livestock

in 2010, the five countries with the greatest projected percentage increases in

antimicrobial consumption by 2030 are likely to be Myanmar (205%), Indonesia

(202%), Nigeria (163%), Peru (160%), and Vietnam (157%) (20). Similarly,

aquaculture sector is known to be a major consumer of antibiotics in SEA andaquatic

environments of the region have been found to contain antibiotics and AMR

genes(21,22). However, no evidence exists on the extent of use of AMAs in this

sector in Myanmar.

National policy on the sale or use of antimicrobials in animals and animal feed is not

well established in Myanmar. Most of antimicrobials used in livestock production are

imported; major classes of antimicrobials, used in livestock production in Myanmar

are beta-lactams, tetracycline, fluoroquinolone, aminoglycoside, macrolides and

sulphonamides. Studies indicate that up to 10% of poultry meats from retail market

have been found to be positive for residue of antibiotics such as fluoroquinolones

(23).

Myanmar has a major existing problem of inappropriate use of antimicrobials, and

most farmers use antimicrobials without any consultation by veterinarians (23). It is

expected therefore that AMR is significant problem in the livestock and food

production sectors.

Similar to human clinical isolates, among ASEAN countries, data on AMR and

foodborne pathogens are limited in Myanmar and therefore doesn’t allow a

meaningful comparison with regional trends(24). Data based on a student thesis

reveals thatSalmonella strains in raw food products in retail markets in Yangon,

Myanmar were all resistant to tetracycline (24). In a study on poultry

meat,Escherichia coli isolates were reported to be resistant to ampicillin,

chloramphenicol, oxytetracycline, and neomycin (69.23% to 61.53%). Moderate

resistance to antibiotics was observed with ciprofloxacin (46.15%). Gentamycin

showed the lowest resistance (7.6%). On the other hand, resistance of E. coli O157

15

isolates from fresh beef samples of retail market ranged from ciprofloxacin (25%)

and gentamycin (87.5%), to sulfamethoxazole/ trimethoprim (12.5%). Antibiotic

resistance of E. coli isolated from rectal swab samples of piglets showed 100%

resistance to ampicillin and oxytetracycline and resistance to chloramphenicol,

ciprofloxacin, gentamycin and sulfamethoxazole/ trimethoprim reported as 75%,

75%, 83.3% and 91.6%, respectively(23).

Situation analysis of AMR containment efforts in Myanmar

A situation analysis was undertaken in Myanmar in September 2016 using a tool

developed by WHO SEARO. The specific objectives of the situation analysis were:

To conduct the situation analysis prior to strengthening and developing the

National Action Plan, aligning with Global Action Plan to determine the

baseline regarding implementation and functionality in terms of sufficient

qualified human resources, funding and functional structures of command and

coordination of AMR program in the country;

To identify opportunity, challenges and implementation gaps in order to

improve the overall NAP implementation;

Assist Myanmar to identify vulnerabilities, opportunities and needs to meet the

68th WHA resolution on AMR and prioritise the activities for AMR containment

as per NAP;

To facilitate WHO in fulfilling its commitment to report on the development,

implementation, monitoring and evaluation of the NAP-AMR and to identify

priority areas for WHO to support.

The situation analysis process comprised of guided discussions between the

National AMR Multisectoral Steering Committee members, senior technical leaders

of national health authorities and veterinary sector, and WHO team. The situation

analysis looked at how well developed the AMR programme was in terms of

governance, policy and systems and its review focused on broad system wide

analysis rather than assessing quality of policies and documents.

The indicators in situation analysis protocol were grouped into seven focus areas: 1.

National AMR Action Plan in line with GAP-AMR; 2. National AMR surveillance

system; 3. Antimicrobial Stewardship and Surveillance of antimicrobial use; 4.

Infection Prevention Control in healthcare settings; 5. Awareness raising; 6.

Research & innovation; and 7. One-Health engagement. These focus areas were

consistent with the five strategic objectives of the WHO GAP-AMR.

Each of the focus areas was comprised of a list of sub-focus areas. Each sub-focus

area was graded on five levels to show the incremental extent of AMP programme

implementation. These five levels of phases are stated as follows: Phase 1: Phase of

exploration and adoption; Phase 2: Phase of programme installation; Phase 3:

16

Phase of initial implementation; Phase 4: Phase of full operation; Phase 5: Phase of

sustainable operation (14).

A thematic situation analysis was conducted based on the phases in which each of

the indicators were placed in. The phases reflect phases of the installation and

implementation of the AMR containment program in terms of governance, policy and

system. Phases 1 and 2 relate to policy development and planning but no

implementation; Phases 3 to 5 are related to different levels of implementation

including initial implementation; phase of full operation; and phase of sustainable

operation. These phases from 3 to 5 are the strengths of the system. Sustainable

operation is considered best practice and defined here as an operation that

incorporate an M&E system.

Figure 1 shows the status of implementation of AMR containment programme in

Myanmar. Green colour indicates complete implementation, yellow indicates partial

implementation and red implies no implementation. Following were the findings from

the Government of Myanmar-WHO Situational Analysis:

National AMR Action Plan in line with GAP-AMR

Myanmar has not started developing a National Action Plan for AMR containment. A

national multisectoral steering committee has been announced with the Deputy

Director General of National Health Laboratory (NHL) identified as the National Focal

Point. Further governance mechanisms to implement plans under different strategic

objectives and interventions will be developed as part of the NAP AMR.

Awareness raising

Awareness efforts in different target groups have been limited and ad hoc and have

ranged from Continuous Medical Educations(CMEs) for professionals (general

practitioners) by public hospitals and professional societies (by Myanmar Medical

Association and General Practitioners’ Society) (25)to modular (NOT curricular)

teaching in professional courses. These efforts have been organized in the last 1-2

years. Limited or no efforts have been made to understand and address awareness

needs of wider target groups base.

National AMR surveillance system

An AMR surveillance system that captures standardized epidemiological, clinical and

laboratory data on AMR has not been set up in Myanmar. Myanmar has a strong

culture of diagnostic microbiology laboratory network. The NHL is the apex lab and

coordinating centre for nearly 1123 hospital laboratories across the country at

different levels. The NHL provides referral and advisory services to other verticals in

MoHS such as DG FDA and Disease Control Programmes under DG Public Health.

Data mostly in paper based form flows from hospital laboratories at different level to

17

the NHL and is comprised of isolates and their AST results without any

epidemiological information. Data is converted to electronic form (excel data) at the

level of NHL followed by limited analysis which is not real time. A long standing QA

program run nationwide as a national EQAS by NHL is another strength of the

laboratory network.

A national referral laboratory for AMR surveillance is yet to be identified. However,

the recently approved and published Myanmar National Policy on Health

Laboratories identifies a central and apex role for NHL(26).

In the absence of systematic data collection and analysis of AMR trends, an early

warning system for emerging trends drug resistance trends is not operational in

Myanmar. Situation analysis revealed some anecdotal evidence of hospital level

analysis on a case-to-case basis following identification of unusual resistance

patterns.

Antimicrobial Stewardship and Surveillance of antimicrobial use

An overwhelming majority of the AMAs used in Myanmar are imported. Import data

provides an opportunity to monitor their use through sales data. Similarly,

surveillance for use in hospital and ambulatory care settings has not been

operationalised.

AMSP as an important strategy for monitoring and improving the use of AMAs in

different health care settings is yet to be introduced in Myanmar’s health sector.

Notably, a National Standard Treatment Guidelines, the treatment guidelines

including for use of AMAs is guided by guidelines issued by professional societies

and adapted by local physicians and surgeons in the hospitals. Local STGs are

seldom guided by local AMR surveillance data.

The institution of DG FDA is the fully functional national drug regulatory authority and

well established as a national network. However, challenges in effective drug control

include, majorly imported medicines, limited human resources for regulatory

enforcement, limited oversight of veterinary drugs and pharmaceutical even though

regulated by DG FDA, lack of awareness on AMR and AMU among stakeholder

across the board and a significant problem of OTC sales of AMAs in both human and

animal sectors. While, the WHO prequalified anti-tuberculosis drugs ensure optimum

quality in national TB program, AMAs for common infections including malaria suffer

from issues of quality, counterfeit drugs and illegal imports from across international

borders.

Infection Prevention Control in healthcare settings

Infection control and patient safety policy was introduced in health care settings by

MoHS some years ago. Infection Control Committees (ICC) and teams are in place

18

under the policy with infection control guidelines. However, except for limited

activities related to education and training in hand hygiene, standard precautions and

additional (transmission related) precautions, there is limited activity of ICCs. Quality

of microbiology laboratory testing is assured by virtue of being part of the NHL

quality assured network. However, there is limited to no analysis of hospital

associated infections data, AMR surveillance and AMU data to prevent infections

and improve of AMAs. Resource constraints including human resource constraints

and lack of standards and guidelines were often cited as the reasons for IPC

programmes not being implemented to their fullest potential.

Research & innovation

In spite of modest institutional capacity, AMR research has not caught the attention

of the research community as is reflected in limited peer reviewed publication base

from Myanmar. Opportunistic research is carried out in clinical settings to fulfil

mandatory academic requirements. A strategic research agenda and priorities for

Myanmar are yet to be identified. A recent publication has highlighted the acute need

for research in program planning and resource allocation but also the need for health

systems, policy and burden research on AMR in tuberculosis control and MDR

TB(27). International collaborations have been established recently by the NHL with

global centres of excellence such as Pasteur Institute, Cambodia, National Centre

for Global Health and Medicine, Japan and Niigata University, Japan.

One-Health engagement

Avian influenza outbreaks have brought together the human and animal health

sectors in the form of coordination mechanisms. As a further step, a One Health

Strategy has recently formulated with a One Health Secretariat being proposed and

led by Central Epidemiology Unit at MoHS. One Health platform will undertake joint

surveillance and response on six priority diseases (avian influenza, rabies, anthrax,

tuberculosis, Japanese encephalitis, food borne zoonoses) and AMR.

Animal health sector in general lags further behind in AMR containment efforts. AMR

containment policy, AMR surveillance, AMSP and awareness programs have not

been initiated. The zoning related interventions following HPAI outbreaks in poultry

are examples of biosecurity and hygiene related interventions that could be

expanded to other settings. Recently The Myanmar Pig Partnership, under the aegis

of Zoonoses and Emerging Livestock Systems (ZELS) project was launched in

Myanmar. The Project is an interdisciplinary research project exploring the disease

risk thought to be accompanying changing pig production and consumption patterns

in Myanmar. It has helped set up basic bacterial culture and antibiotic susceptibility

testing facility at the Veterinary Diagnostic Laboratory (Yangon). AMR surveillance

on a pilot scale is carried out from different sites in and around Yangon area with the

help of local Veterinary Officers. Clinical samples and samples from piggeries,

19

poultry farms, slaughterhouses and feed samples are collected on a monthly basis

and tested for presence of bacterial pathogens and screened for AMR. Few private

farms have started submitting samples for culture and sensitivity to the VDL

(Yangon).Similarly, limited capacity for drug and residue testing is available at

Veterinary Assay Laboratory which is responsible for testing for drug quality before

registering a veterinary drug for import and use in Myanmar. However, this has not

been organized into a systematic surveillance system.

One of the major constraint in controlling AMU in veterinary sector has been the

absence of regulatory control of veterinary sector on licensing, regulating and

controlling AMAs. Veterinary sector is only mandated to recommend and register

AMAs requisitioned by animal production units. The regulatory control by DG FDA at

MoHS lacks effectiveness at the field level.

Overall, AMR containment efforts in Myanmar are in the phase of exploration and

adoption in different focus areas with initial implementation in awareness and

hygiene/sanitation and laboratory surveillance; drug regulation is in process of

achieving full operation (Figure 1).

20

Figure 1: Status of implementation of AMR containment programme/initiatives in

Myanmar, by phase of implementation

21

National Action Plan on AMR (2017 – 2022)

Goal, Objectives and Guiding Principles

The goal of the GAP AMR is: “to ensure, for as long as possible, continuity of

successful treatment and prevention of infectious diseases with effective and safe

medicines that are quality-assured, used in a responsible way, and accessible to all

who need them.”

To achieve this, the GAP-AMR has laid down five strategic objectives which form the

basis for developing public health response to AMR globally. These strategic

objectives are:

Objective 1: Improve awareness and understanding of antimicrobial

resistance through effective communication, education and training

Objective 2: Strengthen the knowledge and evidence base through

surveillance and research

Objective 3: Reduce the incidence of infection through effective sanitation,

hygiene and infection prevention measures

Objective 4: Optimize the use of antimicrobial medicines in human and

animal health

Objective 5: Develop the economic case for sustainable investment that

takes account of the needs of all countries, and increase

investment in new medicines, diagnostic tools, vaccines and other

interventions

Additionally, the NAP AMR is expected to reflect the five principles based on which

the GAP AMR strategies have been enunciated. These include:Whole-of-society

engagement including a One Health approach, Prevention first, Access,

Sustainability, and Incremental targets for implementation(GAP).

NAP Development Process

The development of NAP has followed the guidelines enshrined in WHO’s

“Antimicrobial resistance: A manual for developing national action plans” (World

Health Organization 2016). The approach is structured around the five strategic

objectives and five principles which are embodied by the GAP AMR (World Health

Organization 2015).

22

Within the five strategic objectives of the GAP AMR, 12 specific objectives have

been included. Each of these specific objectives has been described in terms of a

Strategic Intervention, with a defined set of key activities to be carried out

successfully to execute the strategic intervention and eventually to fulfil the strategic

objective. Key Monitoring &

Evaluation (M&E) indicators

have been listed for

activities under each of the

strategic interventions with

the operational plan

comprising of broad

planning by activity. Detailed

planning along with the

budget allotted for the

respective activities will be

done in due course by

national stakeholders.

The NAP thus consists of the Situation Analysis and Assessment, a Strategic Plan,

an Operational Plan as described in the WHO guidance manual and a Sample

template (28,29).

The Situation Analysis by WHO SEARO focused on how well developed the AMR

programme is in terms of governance, policy and system formed the basis for

identifying gaps and strategic priorities (World Health OrganizationSEARO, 2016).

The situation analysis was further supported by literature review including grey

literature provided by country level stakeholders.

Based on the extent of implementation, each of the strategic interventions was

graded on an incremental scale consisting of five phases adapted from the Indicator

Standards Assessment Tool developed by UNAIDS(30). The first phase, that of

exploration and adoption, indicates that the process of designing an AMR

containment programme has been initiated. Once the decision to implement the

programme has been made, systems progress to the second phase, that of

programme installation. The third phase, of initial implementation, is one of the most

challenging phases for programmes in developing countries. Once the early

implementation barrier is overcome and the programme is scaled up, the fourth

stage – full operation – is achieved. Once the programme starts to function at the

highest grade of operational efficiency, the fifth and final stage, that of sustainable

operation, is attained.

Findings from the Situation Analysis helped situate the current state of NAP in the

country along the incremental scale. To enable the country to make the most

progress towards implementing NAP, GAP principle of “Incremental targets for

23

implementation” was followed with the ultimate aim of achieving phase 5 of

sustained operations. Flexibility was built into the planning process including

monitoring and reporting arrangements, in order to allow the country to determine

priority actions that it needs to take in order to attain the five strategic objectives and

implement actions in a step-wise manner that meets both local needs and global

priorities.

NAP development involved the process of participative dialogue with important

stakeholders and informants. Further expansion into a detailed operational by sub

activities and validation will be done by country team and stakeholders. Technical

support was provided by WHO Country office, WHO SEARO and the Consultant.

24

Country Response

Governance A national multi-sectoral governance mechanism is the pivot around which AMR-

related activities can be effectively coordinated in all the relevant sectors. This will

ensure a systematic and comprehensive approach. However, the scope should be

broad enough to address all five strategic objectives of the global action plan,

prioritising activities in a step-wise approach.

The governance mechanism for Myanmar will comprise of a High Level National

Multi-sectoral Steering Committee (NMSC), for antimicrobial resistance. NMSC will

be supported by a National AMR Coordinating Centre and multi-sectoralTechnical

Working Groups who will address the strategic objectives of GAP through

specialised Task Forces on related to the five strategic objectives of GAP. Each of

these will be formed and will function as per the following criteria.

National Multisectoral Steering Committee (NMSC) for Antibiotic

Resistance

The NMSC will provide the necessary political commitment and support for national

AMR containment efforts in Myanmar and to the international global health

community. Given the ultimate goal of AMR containment efforts that are geared to

improve human health outcomes, the NMSC will be formed under the leadership of

MoHS with MoHS as the Chairperson.

Composition of NMSC:

The NMSC will be chaired by Minister for Health & Sports and Co-Chaired by

Minister for Agriculture Livestock& Irrigation. Its membership will be as follows:

Minister of Health and Sports (Chairman)

Permanent Secretary of Ministry of Health and Sports (Co-chair)

Members - 22

National AMR Coordinating Centre (NACC)

The NACC will be the implementation agency for NAP AMR and will draw its powers

and mandate from Ministerial Decree while NMSC will provide strategic vision to

AMR control efforts. The NACC will provide the platform for programme planning and

implementation through a supporting structure comprising of technical working

groups for individual strategic objectives.

25

The NACC is envisioned as a multi-sectoral group of senior programme managers

from different ministries with adequate representation of non-governmental agencies,

cooperatives, civil society representatives, media, international agencies

(WHO/FAO/OIE). By way of its multi-sectoral composition, it will ensure adequate

integration of AMR containment efforts into the existing health system, public health

and disease-specific programmes, animal health and production food sector and

other environmental initiatives.

It will be chaired by Deputy Director General (Labs) and its Secretariat will be located

in NHL, Yangon. Its membership will be drawn from the:

Ministry of Health and Sports

Ministry of Agriculture,Livestock and Irrigation

Ministry of Education

Ministry of Commerce

Ministry of Home Affairs

Ministry of Defence

Logistics of the NACC

The NACC will meet every six months. The NACC Secretariat will be located in NHL,

Yangon.

Roles and responsibilities of NACC:

Roles and responsibilities of the NACC have been mentioned in the Strategic Plan.

Broadly, it will be responsible for:

Planning, implementation and monitoring & evaluation of different strategic

interventions and activities of NAP AMR

Monitoring and evaluation on implementation different strategic interventions and

activities of NAP AMR

Reporting implementation status to NMSC, national agencies and international

partners

Constitute technical working groups and commission task forces for tasks that

include providing technical input for program support and decision-making

Facilitating collaborations with internal and external agencies and organizations,

is essential for many countries especially in the field of surveillance and

innovations

Advocate for prevention and containment of AMR

26

Appointing a National Focal Point

Deputy Director General (Labs) will be the National AMR focal point responsible for

coordinating AMR activities and tasks in the health, animal, aquaculture, food

production and environment sectors. The responsibilities of NFP will be to:

Build sustained partnerships and work nationally and internationally on

containment of AMR;

Identify stakeholders and facilitate formation of an inclusive NACC;

Lead and coordinate drafting of a national action plan for containment of AMR;

Facilitate and oversee implementation, M&E of the plan through the NACC;

Ensure regular data collection and information sharing by instituting effective

communication and coordination among all stakeholders, the members of NACC

and their constituencies, sectors and disciplines;

Coordinate national activities for establishment of AMR surveillance systems

Report on prevalence of and trends in AMR to the Global AMR Surveillance

System (GLASS)

Forming Technical Working Groups

Technical working group (TWG) will form an integral part of the governance

mechanism in Myanmar. These will be multi-sectoral in composition and will report to

the NACC. They will be formed a priory and will be mandated with specific tasks

such as providing technical input, conducting situational analyses, drafting NAPs,

planning and budgeting, commissioning specialised task forces and overseeing

implementation of strategic interventions and corresponding key activities under the

five strategic objectives.

The proposed thematic TWGs that will be formed include:

1. Awareness

2. Surveillance

3. Infection Prevention and Control and Hygiene

4. Optimizing Antimicrobial Use

5. Research and Innovation

Each of the TWGs will be responsible for programme planning and budgeting

referring to NAP on AMR while focusing on One Health and for coordinating between

the different agencies and secretariats. They will assume charge for monitoring and

evaluation and based on their interactions and review mechanisms come up with a

set of workable recommendations.

The 5 TWGs will be mandated by the NACC and will report to their Chairpersons and

to the National Focal Point of the NACC. The organisational structure, composition,

27

locus of coordination centre and general terms of reference are listed below. Specific

jobs of individual TWGs have been detailed in the Strategic Plan Document.

General Terms of References of Technical Working Groups

Technical working group (TWG) will be multi-sectoral in composition and will report

to the NACC. In their respective strategic objective, the TWG will:

Provide strategic direction by identifying intervention and key activities

Conduct situational analyses

Draft detailed sub activity level NAP

Plan and budget for different activities

Monitor and evaluate implementation of strategic interventions and

corresponding key activities

Provide technical input

Commission specialised task forces

Specific terms of references of individual Technical Working Groups and their

structure is detailed in Annexure 2. A Coordinating Unit will support the functioning of

each of the TWGs.

Constituting Specialised Task forces

Specialised task forces will be commissioned by the TWGs for delivering on specific

tasks in the respective strategic areas. They will work under the technical guidance

and supervision of respective TWG and will comprise of in-country as well as

international experts, including those from WHO/FAO/OIE. The Task forces will be

tasked with functions such as evaluation of existing policies, frameworks,

interventions, guidelines and the development of guidelines and standards. They will

be envisioned for the implementation of the Myanmar National Action Plan as

mentioned in the Strategic Plan Document.

28

Figures 2:NAP Governance Structure in Myanmar, 2017-2022

29

Strategic Plan

The strategic plan for Myanmar’s NAP AMR is based on implementation of five

strategic objectives, each of which has its objectives, strategic interventions and key

activities

Strategic Objective 1: AWARENESS

The GAP AMR has identified the need to raise awareness of AMR and promote

behavioural change through public communication programmes that target different

audiences in human health, animal health and agricultural practices as well as a

wide range of consumers related to these sectors. The GAP AMR has also focused

on making AMR a core component of the professional education training,

certification, continuing education and development in the health and veterinary

sectors and agricultural practice. This approach is expected to foster proper

understanding and awareness amongst professionals.

The Situation Analysis revealed that awareness program on AMR in different sectors

is yet to be formalised. Limited and ad hoc CMEs and trainings have been conducted

by tertiary care hospitals, professional societies and veterinary universities.

Awareness for general public and other relevant stakeholders such as livestock

farmers have not been conducted.

By 2022, Myanmar will carry out nationwide evidence based awareness campaigns

with regular M&E. The aim is also to revise curricula in undergraduate medical and

veterinary, food industry and agriculture teaching and Continuous Professional

Development courses. Revised curricula will be implemented on a limited scale but

with regular audits. The Strategic Plan is as follows:

Objective 1.1: To improve awareness of AMR amongst the general

public and professionals

Strategic intervention 1.1 Establish an evidence-based public

communications programme targeting audiences in policy making,

human and animal health practice, the general public and professional

on prudent use of antimicrobials

30

KEY ACTIVITIES

Under the technical guidance of TWG (Awareness):

2017 1. A task force will conduct Knowledge, Attitute and

Practice(KAP).Studies on a national scale on AMR,

AMU,environmental relationships to assess awareness levels

and gaps in knowledge in different target groups. Priority target

groups will include farmers, pharmacists, pharmacies, druggists,

traditional medicine practitioners, primary and secondary school

curriculum, general public and media

2018 2. MoHS and MoALI,in collaboration with MoE, will design evidence

based communication campaigns using evidence generated that

will include accurate and relevant messages targeting priority

groups. Awareness campaigns conducted recently by Myanmar

Medical Association(MMA) andGeneral Practitioner(GP) society

on AMR and AMU will be reviewed for suitability for inclusion in

overall communication strategy

2017-18 3. MoHS and MoALI will identify pilot sites to implement

communication campaign for antibiotic awareness improvement.

Limited scale roll out will be done with support from WHO, FAO

and relevant NGOs

2019 4. Pilot campaigns will be evaluated in 2018. This will be followed

by nationwide scale up and scale out of awareness campaigns in

2019 with regular monitoring and evaluation

Responsible Agency

MoHS, MoALI, MoE, Ministry of Information

Partners and Stakeholders

WHO, FAO, OIE, NGOs & INGOs, MMA, MNA, MMC, GP Society, Livestock

Producers’ Associations, Pharmacists’ Associations, Private Hospital’s

Association

31

Illustrative Indicators

Awareness levels by target groups

Evidence based communication campaigns tailored for specific target groups

Reports on the impact of communication program

Objective 1.2: Improve knowledge of AMR and related topics in

professionals through professional education and training

deployed at the national scale

Strategic intervention 1.2 Include AMR and related topics such as

Infection Prevention Control as a core component of professional

education, training, certification and Development for health care

providers and veterinarians

KEY ACTIVITIES

Under the overall supervision of TWG (Awareness):

2017-18 1. Task Force commissioned in 1.1 will conduct KAP Studies on a

national scale to assess awareness levels and gaps in

knowledge in professional groups on AMR, hygiene & IPC,

environmental relationships. Priority professional groups will

include:specialist physicians/surgeons, general practitioners,

veterinarians, para-veterinarian, paramedics, nursing staff,

environmental health specialists, agriculture/production experts,

ministry officials of relevant departments and policymakers.

2019-20 2. DG , Department of Human Resource for Health (DoHRH)and

MoALI counterpart, under technical guidance of Ministry of

Education, and in collaboration with Medical and Veterinary

Councils will undertake revision for professional development

courses (human and animal health, the food industry and

agriculture). Proposals submitted by Directorate of Medical

Services and ongoing module for undergraduate veterinary

curriculum will be reviewed for their suitability for new curricular

strategies. Roll out of courses will be done on a limited scale

along with concurrent regular audits followed by nationwide scale

up.

32

2020-22 3. AMR and related topics will be incorporated in undergraduate

and postgraduate curricula in human and animal health, the food

industry and agriculture. Limited scale testing of revised

curriculum along with regular audit of courses will be conducted

before planning a nationwide scale up in next phase of NAP

Responsible Agency

MoHS, MoALI, MoE


WHO, FAO, OIE, NGOs & INGOs, MMA, MNA


Awareness levels by professional groups

Number of revised curricula for target professional groups

Audit reports of professional courses

33

Strategic Objective 2: SURVEILLANCE OF AMR

The GAP AMR identifies the need to establish an evidence based surveillance for

AMR in the nation and identifies the following critical information/evidence gaps:

Descriptive epidemiology of resistant organisms as they emerge

Understanding how resistance develops and spreads

The ability to rapidly characterise the emergent resistant organisms

Understanding social sciences, behavioural and other research needed for

holistic fulfilment of all five strategic objectives

Treatment and prevention of infections, especially in the low resource settings

Basic and translational research to support the development of new

treatments, diagnostic tools, vaccines and other interventions

Alternatives to non-therapeutic uses of antimicrobial agents in the context of

agriculture, aquaculture and their use in crop protection

Economic research

The situation analysis revealed that several elements of systematic AMR

surveillance are not in place in different sectors such as surveillance

standards/guidelines, systematic data collection and analysis including electronic

reporting and recording and linkage with HAI surveillance. Human health sector is

ahead with a strong quality assured network of laboratories performing AMR

testing. Disease Control Programs, especially TB, also have an advanced system

of AMR testing. However, animal health sector has only a very recent pilot

initiative in place.

By 2022, Myanmar will consolidate its strengths in AMR surveillance and develop

a high quality AMR surveillance system on a limited scale that will integrate AMR

surveillance in laboratories, hospitals, AMU and surveillance in animal sectors.

By 2022, a national early warning system will be in place to identify early the

emergence of resistance in priority pathogens and to critical

antimicrobials.Nationwide expansion will be planned at the end of this phase of

NAP in 2022. The Plan will be rolled out as below:

34

Objective 2.1: Set up a national surveillance system for

antimicrobial resistance under the leadership of a National

Coordinating Centre.

Strategic intervention 2.1 Establish a national coordination structure for

surveillance of AMR

KEY ACTIVITIES

2017 1. The TWG (Surveillance), TWG (IPC) and TWG (AMU) will

jointly identify an AMR Surveillance Coordination Unit(ASCU),

define its mandates and terms of reference and designate a

Focal Point followed by notification by ministerial decree. The

ASCU will be located in the National Health Laboratory,Yangon

and will comprise of members from NHL, CEU, Veterinary

Diagnostic Lab, Veterinary Assay Lab and Directorate of

Epidemiology (LVBD)

2017-18 2. The ASCU,with technical support from WHO, OIE and FAO, will

develop guidelines for AMR Surveillance including guidelines

for data sharing (indicators, triggers, analysis plan, response

plan), incorporating the critical components as outlined in

guidance documents (WHO sample templates, GLASS

implementation guide, AGISAR technical recommendations,

OIE, Codex Alimentarius, etc).

2017-18 3. The ASCU will identify priority pathogens, sample sites and

pathogen-antimicrobials combinations in humans and animals,

based on the country’s AMR situation

4. ASCU will develop a One Health AMR surveillance plan in

humans, animal and food (sample selection, number of

samples, sample processing, logistics)

5. ASCU will assess and inventory resources for monitoring,

surveillance and testing sentinel environmental sites (hospitals,

animal production units, slaughterhouses, pharmaceutical

manufacturing units etc.) for antimicrobial resistant organisms

and antimicrobial agents

6. ASCU will be responsible for training of surveillance staff and

clinical staff in AMR surveillance and lab techniques according

to GLASS standards

35

7. Under the technical guidance of ASCU, Central Epidemiology

Unit (CEU) will develop an integrated human and animal IT

platform for AMR surveillance reporting. Linkages of information

systems will be established to ensure interoperability between

Lab AMR surveillance of NHL and hospital infection surveillance

in different HCFs. WHONET platform will be implemented for

epidemiological and laboratory AMR surveillance data entry,

storage and transmission in human and animal sector labs.

2019-22 8. ASCU will implement a national AMR surveillance program that

is representative but with limited number of operational sites.

Central Hospitals and their labs, and central veterinary

diagnostic labs (Yangon and Mandalay) and regional veterinary

diagnostic laboratories will be targeted in the pilot phase.

Regular data of AMR along with resistance profiles of priority

pathogens for human, animal and food will be made available to

ASCU from these limited number of sites. Integrated information

system will be integral to the AMR surveillance pilot

9. Under the technical guidance of ASCU, NHL in collaboration

CEU will conduct studies to map antibiotic resistant organisms

in representative environments (hospitals, animal production

units, slaughterhouses, pharmaceutical manufacturing units

etc.), with varying degrees of exposure to antibiotics.

10. Data will be reported, exchanged and queried through the

integrated AMR surveillance IT platform; WHONET platform

implemented by ASCU will be utilised

2021-22 11. The ASCU will establish formal linkages between national AMR

surveillance programme and WHO GLASS. Reporting to

GLASS will commence after formal assessment of national

AMR surveillance program pilots

12. TWG (Surveillance) will conduct a formal assessment of

National AMR surveillance followed by recommendations of

nationwide scale up

Responsible Agency

MoHS (NHL, PHL, CEU, FDA), MoALI (Veterinary Diagnostic Lab, Veterinary

Assay Lab and Directorate of Epidemiology of MoALI)

36


WHO, FAO,OIE


Presence of ASCU with focal point

AMR surveillance standards and guidelines incorporating GLASS standards

and other intergovernmental standards

List of priority pathogens, specimens, pathogen-antimicrobial combinations to

be included in surveillance system

Number of AMR surveillance sites fulfilling requirements of programme

Data reports from surveillance sites

Timeliness and completeness of surveillance reports

Assessment reports of performance of National AMR surveillance programme

Objective 2.2: Build laboratory capacity under the leadership of a

National Referral Laboratory (NRL) to produce high-quality

microbiological data for patient and food-safety management and

support surveillance activities.

Strategic intervention 2.2 Establish a quality assured national laboratory

surveillance network (for AMR surveillance and action)

KEY ACTIVITIES

Under the overall technical guidance of TWG (Surveillance):

2017 1. The National Health Laboratory will be identified as National

Reference Laboratory (NRL) for AMR Surveillance in Myanmar.

NHL will cater to human clinical and water samples. Veterinary

Diagnostic Laboratories will cater to samples animal, animal

feed and food samples and link AMR surveillance with NRL.

The NHL will develop expertise in methods for confirming and

characterising specific pathogens, performing susceptibility

testing, organising quality assurance and participating in

external quality assurance schemes (EQAS). NHL will

subscribe to Thailand EQAS network for a regular EQAS

37

participation in addition to existing project based NCGM

Collaboration. The NHL will coordinate a national network of

surveillance laboratories to monitor AMR in human clinical,

animal and food samples. Further, environmental surveillance

for AMR will be carried out as per 2.1 (8)in human/animal health

surveillance labs.

2. Laboratories linked with AMR surveillance sites in 2.1 will be

identified by the NHL. These surveillance laboratories will be

capable of identifying target pathogens and perform

susceptibility testing as per standard operating procedures

(SOP) laid down by the NHL.

3. The NHL, in partnership with Veterinary Diagnostic Laboratories

will develop and share AMR surveillance standards and

guidelines, including SOPs, incorporating other

intergovernmental standards (OIE/WHO GLASS and

AGISAR/Codex) with surveillance labs.

2018 4. NHL will train surveillance staff, clinical staff, and laboratory

personnel in AMR surveillance, lab techniques and data

management according to international standards (WHO

GLASS and AGISAR, OIE, CODEX)

2018-19 5. Lab surveillance network in support of National AMR

surveillance network will be rolled out in limited number of sites

(Sites identified in 2.1 (8) will be targeted in the pilot phase).

2022 6. TWG (Surveillance) will conduct a formal assessment of

National AMR surveillance network followed by

recommendations for a nationwide scale up.

7. NHL will expand the network into a nationwide quality assured

laboratory AMR surveillance network. NHL will establish

linkages with international and global surveillance and

internationally relevant initiatives (like GLASS, GFN). Reporting

to GLASS will commence from surveillance sites recruited and

operationalised in initial phase.

Responsible Agency

MoHS (NHL, PHL, CEU), MoALI (Veterinary Diagnostic Lab, Veterinary Assay

Lab and Directorate of Epidemiology of MoALI)

38


WHO, FAO, OIE


National Reference Laboratory (NRL) that has expertise in methods for

confirming and characterizing specific pathogens, organising quality

assurance and participates in an external quality assurance scheme (EQAS)

Number of quality assured laboratories supporting AMR surveillance sites

AMR surveillance standards and guidelines incorporating GLASS standards

and other intergovernmental standards

Surveillance staff, clinical staff, and laboratory personnel trained in AMR

surveillance and lab techniques according to GLASS standards

National AMR testing external quality assurance system

Performance reports of NRL and national laboratory network

Objective 2.3: Develop a multi-centric surveillance system on the

national scale to provide early warning of emerging resistance and

monitoring of secular trends at national and sub-national levels.

Strategic intervention 2.3 Establish a systematic, standardized process

to collect, assess and share data, maps and trends on AMR hazards;

develop communication and dissemination systems to ensure

coordination and information exchange; and initiate responses to

warning triggers

KEY ACTIVITIES

Under the overall technical guidance of TWG (Surveillance) and with technical

support from WHO and FAO:

2017-19 1. The ASCU will identify agencies (related to agriculture, human

and animal health, drug control, environmental health) to be

involved in AMR hazard and risk assessment, and outline their

roles and responsibilities

2. The ASCU will frame guidelines and national standards for

39

systematic collection, sharing, and assessment of AMR hazard

events framed in keeping with international standards

(IHR/WHO/OIE/FAO); includes surveillance manual,

investigation/response guidelines, case management guidelines

and lab guidelines.

3. List and definitions of priority events (priority pathogens,

specimens, and pathogen-antimicrobial combinations) will be

developed in keeping with country AMR situation

4. The ASCU will commission CEU to conduct surveys to establish

baseline estimates and trends of AMR to determine risks and

establish thresholds for alerts and action systems

2020-21 5. A central library or database will be established at the ASCU to

store AMR risk information, and make data available to

government agencies, public and international community as

appropriate in future

2021-22 6. Data transmission on AMR alerts will start flowing from initial

phase AMR surveillance sites identified and recruited in 2.1 (8).

Processing of information will be initiated in real time or close to

real time. This will be followed by a comprehensive analysis on

AMU in the human and veterinary sector and its linkage with the

resistance profiles reported in animals and humans by the

laboratory based AMR surveillance programme.

Responsible Agency

MoHS( NHL, PHL, CEU), MoALI ( Veterinary Diagnostic Lab, Veterinary

Assay Lab and Directorate of Epidemiology of MoALI)


WHO, FAO, OIE


AMR risk assessment policy and guidelines in keeping with international

standards (IHR/WHO/OIE/FAO)

List of priority AMR risk triggers

Baseline estimates of AMR trends and thresholds for alerts and action

systems

40

Multi-sectoral Rapid response teams trained response to AMR events

Central database of AMR pathogens and their risk information

Timeliness and completeness of surveillance reports

Assessment reports of performance of national AMR risk Early Warning

System

Strategic Objective 3: HYGIENE, INFECTION PREVENTION

AND CONTROL (IPC)

Infection prevention and control, especially in the context of hospitals, is an important

aspect of a strategic plan to contain AMR since clinical settings represent an

ecosystem of high antimicrobial usage. Within this ecosystem, exist patients, who

may be immunologically impaired. These patients not only represent the population

that is vulnerable to serious, life-threatening infections, at the same time, they

promote the emergence of resistance.

On the other hand, better hygiene (WaSH) and Infection prevention control represent

methods to cut down on the spread of infections in ambulatory human and animal

care facilities, in food production systems and in the community in general.

Vaccination in humans and animals and biosecurity in food production systems are

specific interventions that if implemented effectively, can result in better health

outcomes and reduced risk of emergence of AMR.

The Situation Analysis of measures related to hygiene, infection prevention and

control in human, animal and related sectors in Myanmar reveals platforms that have

been developed. However, in the absence of standardised guidelines, awareness,

training and resources, the quality and scale of implementation has been less than

optimal. Infection control and patient safety program in hospitals and biosecurity and

good animal husbandry practices capacity developed in partnership with FAO

following Highly Pathogenic Avian Influenza(HPAI) outbreaks are platforms that

could be capitalised. Other measures such as AMR stewardship programme in

healthcare settings or ambulatory settings, in human and animal health and food

production sectors and HAI surveillance are yet to be initiated.

The Strategic Plan as outlined below aims to roll out a comprehensive multi-sectoral

national IPC programme on a limited scale in healthcare facilities in public and

private sector and in selected food chains (farms, slaughterhouses, food processors,

aquaculture etc.). Similarly, HAI surveillance will be implemented in few public and

private healthcare facilities. In community settings, formal campaigns for sanitation

and hygiene including biosecurity and animal husbandry practices and food handling

practices on a small scale in animal and food production sites. Human and animal

vaccination are well-developed program that will be further consolidated and

strengthened.

41

Objective 3.1: To establish a national infection prevention and

control programme through full implementation and compliance

with the IPC guidelines within healthcare settings, animal

husbandry systems, fisheries and the food chain

Strategic intervention 3.1 Create a formal organizational structure to

ensure proper development and use of infection prevention and control

policies and strategies in health care settings, animal rearing facilities

and in fisheries

KEY ACTIVITIES

2017-18 1. TWG (IPC) in collaboration with TWG (Surveillance) and TWG

(AMU) will commission a multi-sectoral task force that will

evaluate existing IPC, Hygiene, IPC and Biosecurity components

of Animal Husbandry guidelines and IPC Guidelines in food

production systems. Existing guidelines and programmes on

patient safety in human hospital services will be reviewed for

their strengths and weaknesses including resource constraints

and technical capacity. Biosecurity guidelines developed and

implemented for prevention and control of Avian

Influenza/Pandemic Influenza in partnership with FAO will be

similarly reviewed. The Task Force will develop a national IPC

policy, mandating the creation and harmonization of National IPC

Programmes in healthcare facilities, animal health care facilities,

and food production systems.

Under the overall technical supervision of TWG (IPC):

2017-18 2. The TaskForce on IPC will develop IPC guidelines with

implementation and M&E plans covering infection prevention and

control in all health care settings (hospital and ambulatory) in

human sector including linking it with hospital accreditation

system; IPC/biosecurity in animal health facilities (hospital and

ambulatory), vaccination, and biosecurity in the farm to fork chain

42

in line with international standards set out by OIE/FAO in animal

and food production sectors. Existing guidelines and program will

be reviewed before integration into national guidelines.

3. The Task Force, in collaboration with WHO, FAO, OIE and ASCU

will identify target groups to be trained in IPC from different

sectors (human health, animal health, food

production/agriculture, environment) and at different levels (policy

makers, programme managers, general people, industry leaders,

farmers, etc.).

2019-20 4. TWG (IPC) through DG (DoHRH) and Veterinary Counterpart,

will coordinate capacity building at healthcare facilities to create

dedicated, trained IPC teams at facilities in selected number of

sites including large private hospitals. These should also include

trained biosecurity teams in veterinary hospitals and select levels

to implement and supervise animal farms, slaughterhouses, food

processing industries, etc.

5. DG (DoHRH) and MoALI Counterpart, in collaboration with MoE,

will review existing curricula of professional courses with respect

to content on IPC and develop training modules for incorporation

into professional courses.

2020-22 6. TWG (IPC) through MoHS and MoALI will roll out IPC

programme on a limited scale, with dedicated, trained teams in

place in some public healthcare facilities and private sector and

in selected food chains (farms, slaughterhouses, food

processors, aquaculture etc.).

TWG will conduct a formal assessment of National IPC Programme in 2022, followed

by recommendations of nationwide scale up in all human and animal healthcare

facilities across the nation and across all food production systems.

Responsible Agency

MoHS (HICC), MoALI


National Private Hospitals’ Association, MMA, Livestock Producers’

Associations, ASCC, WHO, FAO, OIE, UNFPA, UNICEF, City Development

Committee

43


Evidence based IPC guidelines

Healthcare workers and staff trained in IPC procedures and guidelines

Number of institutions with IPC programme

Revision of curricula of target professional groups

Number of institutions with reports of IPC programme audit

Performance reports of national IPC programme

Objective 3.2: Decrease Hospital Acquired Infection (HAI) and

associated AMR through facility based HAI surveillance programme

(Human Health)

Strategic intervention 3.2 Implement a healthcare facility-based HAI

surveillance system along with related AMR surveillance (human health).

KEY ACTIVITIES

2017-18 1. The TWG (IPC) will commission a multi-sectoral task force that

will, as part of Hospital IPC Guidelines, develop guidelines for

HAI surveillance (objectives, standardised case definitions,

methods of detecting infections/procedures/exposures and

exposed populations, process for analysis of data, evaluation of

data quality, reporting/communication lines at local level and

from local to national facilities, quality assured microbiology

capacity, training programme, financial outlays).

2019-22 2. ASCU will implement on pilot scale a HAI surveillance in select

public and private healthcare facilities. HAI surveillance data will

be reported centrally from these public and private healthcare

facilities.

2022 3. ASCU will carry out a formal assessment of HAI surveillance

pilot. Data from HAI surveillance network will be integrated into

National AMR surveillance network as outlines in 2.1 (7).

Integrated analysis of surveillance data will form the basis for

monitoring and response frameworks, including the identification

of priority triggers (priority pathogens or pathogen-drug

resistance combination) that will be established by ASCU. HAI

44

surveillance will be implemented on a national wide scale

covering central, regional, referral, township, district and rural

hospitals in public and sentinel private hospitals/chains of

hospitals

Responsible Agency

MoHS (HICC)


National Private Hospitals’ Association, MMA, WHO, UNFPA, UNICEF


National HAI surveillance standards and guidelines

Number of HAI surveillance sites

Performance reports of national HAI surveillance programme

Objective 3.3: To limit the development and spread of AMR outside

health settings

Strategic intervention 3.3 Promote sanitation and hygiene by social

mobilisation and behavioural change activities

KEY ACTIVITIES

2017 1. The TWG (IPC), in collaboration with MoE, will commission a

multi-sectoral task force. The Task Force will review and evaluate

the existing national campaigns, generate new evidence

wherever necessary and modify guidelines suitably to address

issue of sanitation and hygiene including, food handling practices

and vaccination in humans and animals.

Under the overall technical supervision of TWG:

2018 2. MoHS and MoALI will implement formal campaigns for sanitation

and hygiene including biosecurity and animal husbandry

45

practices, food handling practices and vaccination on a small

scale in animal and food production sites.

3. MoALI will strengthen immunization programmes for preventable

infections; MoHS and MoALI will evaluate existing vaccination

programme for their effectiveness and coverage

2018-19 4. MoHS and MoALIin collaboration with MoE will include sanitation

and hygiene including food handling practices in the core

curricula in secondary and undergraduate education for school

and college students

2019 5. MoHS and MoALI will carry out monitoring and concurrent

evaluation of campaigns on sanitation and hygiene to inform

nationwide scale-up,

Responsible Agency

MoHS (HICC), MoALI


National Private Hospitals’ Association, MMA, UNFPA, UNICEF, MoE,

Ministry of Information, WHO, FAO, OIE, NGOs, MMA, GP Society, City

Development Committee


Campaign for sanitation and hygiene

Number of revised curricula for target groups with sanitation and hygiene and

safe food handling in the core curriculum

Vaccination coverage rates

46

Strategic Objective 4: OPTIMISE USE OF ANTIMICROBIAL

MEDICINES

Use of antimicrobials in any form, even when rational and prudent, can precipitate

resistance in target microbes. High antibiotic use may reflect over-prescription, easy

access through over-the-counter sales, and more recently sales via the Internet

which are widespread in many countries.

The situation analysis reveals that Myanmar has a fully functional National

Regulatory Authority that is responsible for regulation and licensing;

pharmacovigilance and market authorization. Post licensing inspections including for

retail pharmacies and OTC sales are carried out on national scale but with limited

effectiveness, given the complex challenges of mostly import based system of

procurement and illegal drug movement. The country lacks important instruments

and systems such as a National AMR containment policy, AMU surveillance

including sales of antimicrobial agents. Animal health sector lags on all of the above

fronts and is also constrained by lack of regulatory powers.

Myanmarwill establish a robust system for regulation and surveillance of use of

antimicrobial agents for control of use of antimicrobial substances in human,

veterinary and food production sectors. Some of the measures taken will include a

National AMR Containment and Use Policy and related regulatory frameworks,

National Drug Policy, National Drug Regulatory Authority for Veterinary Sector,

essential medicines list and standard treatment guidelines with special reference to

use of antimicrobial agents, evidence based guidelines for National Antimicrobial

Stewardship Programme an AMU monitoring programme in human and animal

health care, ambulatory and community settings and food animals including,

residues testing in food products. All of the above systems to optimise use of

antimicrobials, however, will be implemented on a limited scale during 2017-2022.

Formal assessments will be carried out at the end of this period before nationwide

scale up. The Strategic Plan to establish the above is as outlined below:

Objective 4.1: Establish a national AMR containment policy,

Antimicrobial Stewardship Programmes (AMSP) and Standard

Treatment Guidelines (STG) at the national scale for prudent use of

antimicrobials

47

Strategic intervention 4.1 Create a national AMR containment policy for

control of use of antimicrobials in humans and animals, and establish a

comprehensive evidence-based formal antimicrobial stewardship

programmes at the national level

KEY ACTIVITIES

The TWG (AMU) in collaboration with TWG (Surveillance) and TWG (IPC) will

commission a task force to develop a National AMR Containment and Use Policy

and related regulatory frameworks. Within this policy framework, the task force will:

2017-19 1. Propose a formal organisational structure responsible for

implementation of the National AMR containment policy. The

Policy will mandate provisions for the five strategic objectives

enshrined in GAP and NAP AMR for Myanmar

2. Formulate regulatory framework for control of human and

veterinary use of antimicrobial substances, including but not

limited to the phasing out of Antimicrobial Growth Promoters

(AGPs) and establishment of system for certification of farm

products free from antibiotic residue

3. Under supervision of DG FDA and DG Medical Services, develop

an essential medicines list with special reference to use of

antimicrobial agents. Antimicrobial agents in the EML will be

considered for inclusion based on Myanmar’s situation of current

levels of AMR, availability, supply chains, financial outlays and

international guidelines and standard treatment guidelines in

human medicine, veterinary medicine, aquaculture and food

production (including antimicrobial growth promoters; AGPs).

4. STGs (including antimicrobials) will be developed by the

taskforce for training, supervision and supporting critical decision-

making in antimicrobial use practices, in human and veterinary

healthcare and food production section

5. Conduct baseline surveys to assess the extent, barriers and

enablers of AMSP at institutional levels

6. Develop comprehensive, evidence based guidelines for a

National Antimicrobial Stewardship Programme (AMSP) with aim

of improving and measuring the appropriate use of antimicrobials

in human and animal health care, ambulatory and community

48

settings as well as aquaculture.

Under the overall supervision of TWG (AMU)

2018-22 7. DG Medical Services (MoH) and DG LVBD (MoALI) will

implement AMR policy for control of human and veterinary use of

antimicrobial substances, including the phasing out of

Antimicrobial Growth Promoters (AGPs). Limited scale

implementation of the national AMSP in human and animal

health care, ambulatory and community settings and food

animals will be done. This will be accompanied by monitoring and

concurrent evaluation followed by nationwide implementation in

the next phase of NAP.

Responsible Agency

MoHS (DG FDA, DG Medical Service) & MoALI (DG LBVD)


WHO, FAO, OIE


Evidence based national standard treatment guidelines

National Essential medicines list

Regulatory framework for control of human use of AMAs

Comprehensive, evidence based National AMSP guidelines for health care

and community settings addressing the core areas

Performance reports of National AMSP

Objective 4.2: Regulation of post-marketing quality of drugs under

the leadership of an NRA/DRA to ensure access to quality

antibiotics

49

Strategic intervention 4.2 Strengthening of a competent National

Regulatory Agency (NRA) or Drug Regulatory Agency (DRA) which can

enforce quality standards of antimicrobial drugs (veterinary, human, and

food production sectors)

KEY ACTIVITIES

Under the overall supervision of TWG (AMU):

2017 1. DG FDAin collaboration with a suitable counterpart in DG LVBD

will formulate a National Drug Policy with special reference to

AMAs and AMR. The Policy will be applicable to human and

animal health, aquaculture and food production sectors. The

Policy will be made available in the public domain

2017-19 2. MoHS will further strengthen DG FDAin serving its mandates of

drug control, import, manufacture, quality, distribution, pricing,

market authorization, advertising, retail sales, and inspection,

and to implement the relevant policies. DG FDA will cover drugs

used in human health (and support regulation of animal health,

aquaculture and food production till the time the Veterinary FDA

is fully functional).

3. MoALI will establish a National Drug Regulatory Authority

(NDRA) on the lines of and with mandates similar to DG FDA.

The MoALI FDA will cover drugs used in animal health,

aquaculture and food production.

4. The NDRAs will develop regulations and quality checklists for

AMAs, APIs and OTC sales.

5. NDRAs will establish a system for the coordination and collation

of data on drug quality (including supply, storage, transportation)

from different sources or parts of the nation; tracking and

reporting suspected product quality and treatment failure. The

system will be implemented by regional FDAs. Special attention

will be given to international border areas known for illegal import

of drugs

2017-22 6. Within the regulatory frameworks laid down by NDRA, the MoHS,

and MoALI will establish an institutional network with the capacity

for quality control of antimicrobial agents or APIs. Existing system

50

of inspection by national and regional FDAs of MoHS will be

reviewed for its efficiency. Regional FDAs will be strengthened

and set up and will be responsible for carrying out inspections in

different types of pharmaceutical establishments; formal

registration procedures for drugs; and legal provisions for penal

sanctions for non-compliance. Relevant authorities within the

regional FDAs will be tasked with their implementation and

enforcement of regulatory provisions. Human resources will be

adequately provisioned for effective monitoring and enforcement

7. Regional FDAs will also be responsible for strengthening the

pharmaceutical supply chain, including the procurement, supply

and management system in human health, veterinary and food

production sectors

8. TWG (AMU) in collaboration with CEU and veterinary counterpart

will conduct independent periodic surveys to estimate the extent

of OTC and inappropriate sales of antibiotics and APIs and the

drivers for the same and evaluate the effectiveness of OTC

regulations done and corrective measures undertaken

2022 9. During first years of NAP, MoALI drug regulation will be enforced

in limited areas of Myanmar with special focus on international

borders. Nationwide implementation of drug regulatory system

will be possible by 2022

Responsible Agency

MoHS (DG FDA, DG Medical Services) & MoALI (DG LBVD)


WHO, FAO, OIE


National DRAs with appropriate mandate, TORs, membership and leadership

National Drug Policy

Regulations for import, export, local production, distribution and use of

finished AMAs and APIs and OTC sales

Guidelines for drug quality management system (manufacturing, registration,

supply, storage, transport, inspection and legal provisions for penal sanctions

for non-compliance)

51

Number of drug quality monitoring sites; Estimates of OTC sale of AMAs and

APIs

Objective 4.3: Establish mechanisms to monitor antimicrobial

usage on a national scale to inform interventions to reduce overuse

and promote prudent use of antimicrobial substances

Strategic intervention 4.3 Monitoring antimicrobial use (AMU) and sales

in humans, animals and fisheries; monitor trends of residues of

antimicrobials in food chains to inform interventions to promote prudent

use of antimicrobials

KEY ACTIVITIES

Under the overall technical guidance of TWG (AMU), TWG (Surveillance) and

TWG (IPC)

2017 1. ASCU will establish a subcommittee called Antimicrobial Use

Surveillance Committee (AUSC) with appropriate mandate,

TORs and Focal Point (FP) that links with ASCU

2018 2. The AUSC will coordinate policies on AMU and monitoring their

impact on AMR. ASUC will design an AMU monitoring program in

humans and food animals including, residues testing in food

products (guidelines and standards for surveillance design, data

type, reporting formats, reporting sites, sources of antimicrobial

usage/sales data, list of indicators). AUSC will monitor sales data

in humans as well as animals (sales quantity per kg of

slaughtered animal, sales quantity per PCU etc.). In addition,

point prevalence surveys will be conducted in collaboration with

CEU and Veterinary counterpart to assess quantity and quality of

AMU in different settings. Longitudinal surveillance will be

planned in the next phase of NAP.

3. In collaboration with Veterinary Assay Laboratory, AUSC will also

develop guidelines to implement residue testing including data

sharing

52

2019-22 4. AUSC will implement AMU surveillance and residue testing.

Healthcare facilities, including in ambulatory and community

settings (human and animal pharmacies etc.) and parts of animal

husbandry chains (e.g. farm level) will be recruited on a limited

scale. For residue testing, surveillance sites operationalised for

AMR Surveillance in 2.1 (7) will be recruited. AMU surveillance

and residue testing will be conducted on limited scale by 2022.

Data for the use of antimicrobial substances and sales data in

humans, animals, and food production sectors will be available

by 2022

5. The AUSC will analyse AMU data in linkage with the resistance

profiles reported by the AMR surveillance programme. Actionable

recommendations will be made to modify existing local STGs

Responsible Agency

MoHS (HICC, Medical Care, FDA), MoALI (Epidemiology, MoALI FDA,

Veterinary Assay Lab)


Ministry of Commerce, WHO, FAO, OIE


AMU surveillance and monitoring system

Sales data for AMAs at the national level

Actionable recommendations on modifying AMU to contain AMR

53

Strategic Objective 5: (ECONOMIC) CASE FOR

SUSTAINABLE INVESTMENTS AND INCREASE

INVESTMENTS IN NEW MEDICINES, DIAGNOSTIC TOOLS,

VACCINES AND OTHER INTERVENTIONS TO REDUCE

ANTIMICROBIAL USE

The GAP AMR posits that the economic case should reflect the need for capacity

building and training in low resource settings, while developing evidence based

interventions to reduce infections and combat AMR. The 2001 strategy for AMR

containment could not achieve its goals; one of the reasons cited for the same is that

there was absence of economic assessments, which evaluated the cost of doing

nothing versus the cost/benefits of action at the present.

The Situational Analysis in Myanmar indicates that research on AMR has not been a

priority for both policy makers and research community. Given the widespread

irrational use of AMAs, AMR is expected to be sizable public health threat, as has

been demonstrated in MDR-TB rates in the country. This calls for policy and program

relevant research to support planning and implementation of public health

interventions. The phase of development of the health system provides an

opportunity to put in place strategic research agenda for public health research and

AMR in particular to inform health system responses.

The Strategic Plan lays down a roadmap for establishing a strategic research

agenda, with systematically prioritised research areas and knowledge gaps related

to AMR that will feed into a national policy for research and innovation. By 2022,

multi-stakeholder platform and research consortia will be established that will

generate program and policy relevant evidence on and compare cost effectiveness

of AMR control strategies. The strategic plan also envisions collaborations with

national and international agencies, for implementation of strategic research agenda.

This will be one of the key strategies for Myanmar, given its existing nature of AMR

threat and limited institutional capacity.

Objective 5.1: To promote sustainable investment in new

medicines, diagnostic tools, vaccines and other interventions by

developing a strategic research agenda and national research

policy

54

Strategic intervention 5.1 Generate cost effectiveness and benefit

evidence for reducing AMU & AMR; develop a national strategic

research agenda

KEY ACTIVITIES

Under the overall supervision of TWG (Research):

2017-18 1. The Department of Medical Research (DMR) will create an

inventory of relevant networks, initiatives, institutions and experts

involved in AMR research across human and animal health

sectors in Myanmar. The DMR will assess existing research,

capacities, future plans and funding sources for research and

innovations through a landscape analysis.

2. DMR will develop a Strategic research agenda, with

systematically prioritised research areas and knowledge gaps

related to research and innovation in the field of AMR, and

resource needs that are relevant for Myanmar (in terms of human

resources, materials and funding). Priority research will include:

a. Research to estimate and characterize burden and risk of

AMR and AMU in human, animal and food production

sectors including prescribing behaviours as well as

treatment and care-seeking, barriers and drivers for

uptake of prudent antimicrobial use practices. Special

focus will be on broader socioeconomic burden of

antimicrobial resistance and cost effectiveness and

feasibility of interventions to reduce AMR and AMU across

different sectors.

b. Systems and policy research including operational

research to understand and improve priority areas such as

regulatory frameworks and their enforcement, stakeholder

analysis, human resources, supply chains, public private

partnerships, interoperability between different elements of

AMR control plans and sectors, information management

systems, AMR and AMU surveillance and use in health

care and ambulatory settings across sectors, laboratory

support

2017-18 3. TWG (Research) will develop a national policy for research and

55

innovation, including research into alternatives for AMU

practices, based on the research agenda drawn up by the DMR

2018-19 4. TWG (Research) will establish a multi-stakeholder platform to

guide AMR research and innovation. The research platforms will

develop research consortia, and establish collaboration with

national and international agencies, for implementation of

strategic research agenda

2020-22 5. TWG (Research) will make evidence available through research

databases, peer reviewed publications, policy briefs, policy

advocacy dialogues to inform national and local policies and

strategic interventions in different strategic objectives to reduce

the need for antimicrobial in several settings (health care, animal

husbandry, aquaculture and food production)

Responsible Agency

MoHS (Directorate of Medical Research) & MoALI (Research &Development Unit)


WHO, FAO, OIE, National Health Laboratory, TAG of Clinical Domain &

Public Health Domain, Universities of Medicine, University of Public Health,

CEU, University of Veterinary Sciences


Research network and collaborations

Multi-stakeholder research initiative National Research Policy on AMAs and

AMR Research

Strategic research agenda, with prioritised research areas, and resource

needs in the field of AMAs and AMR

Peer reviewed publications, policy briefs, policy dialogues

56

Way Forward

The National Action Plan for prevention and control of AMR in Myanmarhas been

prepared by stakeholders from different ministries in Myanmar. The Plan is a

Strategic Plan with Operational details. The Plan takes cognizance of the limitations

and capitalizes on the strengths and emerges as a comprehensive document that

describes the country’s vision of AMR prevention and control.

The Plan has built upon some of the critical insights that have emerged from the

Situation Analysis and a host of interviews, guided discussions and participative

dialogues that have been undertaken with multiple stakeholders. The NAP AMR of

Myanmar in its current form provides a constructive opportunity for the government

to fine tune it based on its local realities and sensitivities. Most importantly, it

presents an affirmative statement of goals, objectives and strategic interventions that

will be deployed to achieve the objectives set out clearly in the document.

The strategic plan envisions collaborations with national and international agencies,

for implementation of a strategic research agenda that will serve as a major strategy

for the country, given its urgent evidence needs to guide program planning and

action. Essential elements of AMR containment which have so far not completely

taken off the ground will now see movement as comprehensive awareness

programmes are conducted, surveillance of AMR and AMU including laboratory

capacity, IPC and AMSP are strengthened and other public health functions are

aligned to the new AMR goals.

Following submission of the final report to the World Health Assembly, the

Government of Myanmarwill continue with its deliberations and planning process

under the leadership of NMSC. Next, the NMSC through its constituent NACC,

TWGs and Task Forces will draw up a detailed operational plan in addition to its

budget and monitoring and evaluation plan for successful implementation of the

activities. Most of these activities will be implemented by the key actors as outlined in

the strategic plan that covers the period 2017-22.

The successful implementation of the NAP AMR will bring together all the critical

players from the human and animal health and related domains creating greater

responsibility, ownership and transparency. Working closely with a more sensitised

and aware population, the country will bring down its levels of AMR and going

forward institutionalise mechanisms to arrest its spread.

.

57

References

1. World Health Organization. Global action plan on antimicrobial resistance. Geneva; 2015.

2. Van Boeckel TP, Brower C, Gilbert M, Grenfell BT, Levin SA, Robinson TP, et al. Global trends in antimicrobial use in food animals. Proc Natl Acad Sci. 2015;112(18):5649–54.

3. Van Boeckel TP, Gandra S, Ashok A, Caudron Q, Grenfell BT, Levin SA, et al. Global antibiotic consumption 2000 to 2010: An analysis of national pharmaceutical sales data. Lancet Infect Dis. 2014;14(8):742–50.

4. Center for Disease Dynamics Economics and Policy, Global Antibiotic Resistance Partnership. The State of the World’s Antibiotics, 2015. Washington DC; 2015.

5. World Health Organization. United Nations high-level meeting on antimicrobial resistance. Antimicrobial Resistance. World Health Organization; 2016. p. 3.

6. United Nations Development Programme. About Myanmar [Internet]. [cited 2017 Mar 12]. Available from: http://www.mm.undp.org/content/myanmar/en/home/countryinfo.html

7. Yong YL, Plançon A, Lau YH, Hostetler DM, Fernández FM, Green MD, et al. Collaborative health and enforcement operations on the quality of antimalarials and antibiotics in southeast Asia. Am J Trop Med Hyg [Internet]. 2015;92(6 Suppl):105–12. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25897069%5Cnhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4455084

8. Asia WHORO for S-E. Health in the Sustainable Development Goals, Where we are now in the South-East Asia Region? What next? World Health Organization, Regional Office for South-East Asia; 2016.

9. Unpublished. MDR-TB challenges in Myanmar, what are the hopes? Meeting of the National Committee for MDR-TB Management, Nay Pyi Taw, 17 March 2014. Nay Pyi Taw; 2014.

10. Myat TO, Prasad N, Thinn KK, Win KK, Htike WW, Zin KN, et al. Bloodstream infections at a tertiary referral hospital in Yangon, Myanmar. Trans R Soc Trop Med Hyg [Internet]. 2014 Nov;108(11):692–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25253617

11. Mendes RE, Mendoza M, Banga Singh KK, Castanheira M, Bell JM, Turnidge JD, et al. Regional Resistance Surveillance Program Results for 12 Asia-Pacific Nations (2011). Antimicrob Agents Chemother. 2013 Nov;57(11):5721–6.

12. Chalmers L, Cross J, Chu CS, Phyo AP, Trip M, Ling C, et al. The role of point-of-care tests in antibiotic stewardship for urinary tract infections in a resource-limited setting on the Thailand-Myanmar border. Trop Med Int Heal. 2015;20(10):1281–9.

58

13. Shwe TN, Nyein MM, Yi W, Mon A. Blood culture isolates from children admitted to medical unit III, Yangon Children’s Hospital, 1998. Southeast Asian J Trop Med Public Health. 2002;33(4):764–71.

14. Lestari ES, Severin JA, Verbrugh HA. Antimicrobial resistance among pathogenic bacteria in Southeast Asia. Southeast Asian J Trop Med Public Health [Internet]. 2012;43(2):385–422. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23082591

15. Food and Agriculture Organization. Myanmar at a glance [Internet]. 2017 [cited 2017 Mar 12]. Available from: http://www.fao.org/myanmar/fao-in-myanmar/myanmar/en/

16. Haggblade S. A Strategic Agricultural Sector and Food Security Diagnostic for Myanmar. 2013.

17. Embassy of the Kingdom of the Netherland. Agriculture in Myanmar. 2015;(January):1–4. Available from: http://thailand.nlambassade.org/binaries/content/assets/postenweb/t/thailand/nederlandse-ambassade-in-bangkok/import/producten_en_diensten/handel_en_investeren/zakendoen_in_myanmar/factsheet-agriculture-in-myanmar-2015.pdf

18. Food and Agriculture Organization. The Union of Myanmar [Internet]. 2006 [cited 2017 Mar 12]. Available from: http://www.fao.org/fi/oldsite/FCP/en/MMR/profile.htm

19. Grace D. Review of Evidence on Antimicrobial Resistance and Animal Agriculture in Developing Countries. Availableat https//cgspace.cgiar.org/handle/10568/67092 Accessed 29 Oct 2015. 2015;(June):5–7.

20. Van Boeckel TP, Brower C, Gilbert M, Grenfell BT, Levin S a, Robinson TP, et al. Global trends in antimicrobial use in food animals. Proc Natl Acad Sci U S A [Internet]. 2015;(16):1–6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25792457

21. Nazaret S, Aminov R. Role and prevalence of antibiosis and the related resistance genes in the environment. Front Microbiol. 2014;5(SEP):1–2.

22. Suzuki S, Hoa PTP. Distribution of quinolones, sulfonamides, tetracyclines in aquatic environment and antibiotic resistance in Indochina. Front Microbiol. 2012;3(FEB):1–8.

23. Food and Agriculture Organization fo the United Nations Regional Office forAsia and the Pacific. International Workshop on the Use of Antimicrobials in Livestock Production and Antimicrobial Resistance in the Asia-Pacific Region. In Negombo, Sri Lanka: Food and Agriculture Organization fo the United Nations Regional Office forAsia and the Pacific; 2012. Available from: http://cdn.aphca.org/dmdocuments/AMR WS Proceedings_121112.pdf

24. Archawakulathep A, Thi Kim CT, Meunsene D, Handijatno D, Hassim HA, Rovira HRG, et al. Perspectives on antimicrobial resistance in livestock and livestock products in ASEAN countries. Thai J Vet Med. 2014;44(1):5–13.

59

25. Myanmar Medical Association. 18th General Practitioners’ Scientific Conference: Respiratory Infection. Yangon; 2017.

26. Ministry of Health and Sports. Myanmar National Policy on Health Laboratories. The Union of The Republic of Myanmar; 2016.

27. Khan MS, Schwanke Khilji SU, Saw S, Coker RJ. [Accepted Manuscript] Evidence to inform resource allocation for tuberculosis control in Myanmar: a systematic review based on the SYSRA framework. Health Policy Plan [Internet]. 2016;(June 2016):102–9. Available from: http://researchonline.lshtm.ac.uk/2965038/1/Updated Myanmar TB Sys Review R1_10 May 2016 %281%29.docx

28. World Health Organization. Antimicrobial Resistance: A manual for developing national action plans. 2016.

29. World Health Organization. Template for a national action plan on antimicrobial resistance. 2016.

30. Monitoring and Evaluation Research Group. Indicator Standards: Operational Guidelines for Selecting Indicators for the HIV Response. Geneva; 2010.

60

Annexure 1: Interpretation of phase of AMR prevention and

control program implementation

Phase of

Programme

Implementation

What it means

Phase 1

Phase of

Exploration and

Adoption

There are no programmes implemented in a systematic manner

in order to conduct AMR prevention and control in the country.

However, the process of designing a program has been initiated,

and depending on the progress made (as seen through the

indicators), it may be that one or more of the following activities

are being undertaken:

- Identification of needs, options and resources

- Identification of potential barriers to implementation

(funding, human resources, system responsiveness, etc.)

- Investing in systems to augment their readiness to deploy

the programme and overcome the identified barriers in

implementation

- Identifying structures (both in policy making and

implementation frameworks) to aid in the implementation

of the programne

As the nation gets closer to the end of Phase 1, it is on the verge

of implementing (at any scale, even a pilot project) an AMR

surveillance programme.

Phase 2

Phase of

Programme

Installation

The decision toimplement a programme has been made and

the initial set of activities have been undertaken in order to launch

the program. These may include:

- Capacity building

- Resource allocation

- Establishment of data transmission, security, and sharing

protocols

- Development of process indicators, standard operation

protocols and other guidelines to be adhered to by

institutions participating in the programme

61

In course of the second phase, there is more emphasis on

development of infrastructure, and allocation of resources in

order to implement a programme in a defined context and then

scale it up to the national context in the subsequent phases.

Phase 3

Phase of Initial

Implementation

This is probably the most challenging phase in the stages of

earlyimplementation of any programme within the context of

developing nations. In this phase, there is a need to initiate a

change or an intervention, which may have patchy uptake or

maybe avoided altogether.

- In course of this phase, a functional model of the program

is identified

- All protocols, SOPs, etc. undergo a real world challenge

This is a very crucial phase and most programs are likely to find it

difficult to come out of this phase.

Phase 4

Phase of Full

Operation

This is the process of scaling up a successful model of the

programme that may have been trialled in the previous phase.

- The programme is part of accepted practice

- There is a nation-wide (or a large scale) adoption of the

programme

- The programme is functional by generating outputs and

outcomes on a regular basis (seek proof of evidence)

Phase 5

Phase of

Sustainable

Operation

This is the highest grade of operational efficiency of the

programme and indicates that the programme can have long-

term survival.

- The programme is resilient to changes in funding volume,

partner agency support, etc. external factors which were

essential for installation and initial implementation of the

programme.

- Through a functional M&E mechanism, there is systematic

improvement of capacity, especially in human resources

and system capacity, to enable the programme to function

without extensive need to invest in continued capacity

building

62

Annexure 2: Terms of reference of individual Technical

Working Groups and their structure

Technical working group SO1 (Awareness):

Terms of Reference

• Plan, implement, monitor and evaluate strategic interventions for improving

awareness and antimicrobial use practices in different target groups, including

professionals in human health, animal health and agriculture sectors

• Facilitate designing of and guidelines for evidence based campaigns for

awareness generation on AMR and related issues

• Coordinate between different sectors, with educational councils and

professional associations on issues related to increasing awareness for AMR

and related issues

• Coordinate with different TWGs for smooth implementation of the NAP

• Report to NMSCthrough its Chairperson annually

Structure

• Chairperson/Responsible Dept.:

• Secretariat location:

• Members:

Technical working group SO2 (Surveillance):

Terms of Reference

• Identify a National Coordination Centre (NCC), define its mandates and terms

of reference and designate a National Focal Point followed by notification

• Facilitate development of guidelines for national AMR Surveillance program

including guidelines for data sharing (indicators, triggers, analysis plan,

response plan), incorporating the critical components as outlined in guidance

documents

• Plan and implement, strategic interventions under the national program for

AMR surveillance in human health, animal health and agriculture sectors

including quality assured laboratory network and early warning systems. This

will include identifying implementation agencies, partner agencies, scope of

activities, budgetary outlays

• Coordinate with TWG (AMU) to facilitate integrated analysis of AMR and AMU

surveillance

• Monitor and evaluate national AMR surveillance program

• Facilitate maintenance of AMR and AMR risk data bases

• Provide comprehensive and stratified analyses of trends of AMR and AMU

across different sectors, AMAs, commodities, species, settings etc.

63

• Make recommendations on AMR prevention/control/containment and rational

use of AMAs

• Report to NMSCthrough its Chairperson annually or on urgent basis in case of

an early warning

• Facilitate surveillance information sharing across sectors and with relevant

international agencies/networks

Structure



• Members:

Technical working group SO3 (IPC):

Terms of Reference

• Develop a national IPC policy, mandating the creating of a National IPC

Programme in healthcare facilities, animal health and food production systems

and national HAI surveillance in health care facilities

• Facilitate development of guidelines for National IPC program in human and

animal health care and ambulatory facilities, and food production systems

• Plan and implement, strategic interventions for the national IPC program in

human health, animal health and agriculture sectors including identifying

implementation agencies, partner agencies, scope of activities, budgetary

outlays

• Coordinate with TWG (Surveillance) to facilitate integrated analysis of AMR,

AMU and HAI surveillance

• Monitor and evaluate national IPC surveillance program


use of AMAs

• Report to NMSCthrough its Chairperson annually or on urgent basis in case of

an early warning

Structure



• Members:

Technical working group SO4 (AMU):

Terms of Reference

• Facilitate strengthening of existing systems and establish new regulatory

systems for control of AMAs sale and use.

64

• Facilitate development and implementation of national drug policy and within

the policy framework guidelines and standards to improve AMU. The

standards and guidelines will include EMLs and STGs

• Plan and implement, strategic interventions for the national AMSP program in

human health, animal health and agriculture sectors including identifying

implementation agencies, partner agencies, scope of activities, budgetary

outlays

• Coordinate with TWG (Surveillance) and TWG (IPC) to facilitate integrated

analysis of AMR, AMU and HAI surveillance

• Monitor and evaluate national AMSP program


use of AMAs

• Report to NMSC through its Chairperson annually or on urgent basis in case

of an early warning

Structure



• Members:

Technical working group SO5 (Research):

Terms of Reference

• As part of a national policy for research and innovation, facilitate development

of strategic research agenda, with systematically prioritised research areas

and knowledge gaps to guide research and innovation in the field of AMR

• Facilitate establishment of research platforms, research consortia, research

funding opportunities and collaboration with national and international

agencies, for to promote research and implement strategic research agenda

• Communicate evidence available through research databases, peer reviewed

publications to policy and program community for evidence based policy

making and program planning

• Monitor and evaluate research efforts on AMR in Myanmar

• Report to NMSC through its Chairperson annually or on urgent basis in case

of an early warning

Structure



• Members:

national action plan for containment of antimicrobial ... · antimicrobial resistance (amr) has...

Documents